Endocrine Abstracts

Case report: A previously fit 53-year-old lady presented to A&E with abdominal pain and vomiting. The pain has been present for 2 months and associated with weight loss. She neither smoked nor drank alcohol. On admission her BP was 160/85, pulse 70/m regular. Abdominal examination revealed generalized tenderness and a right iliac fossa mass with scanty bowel sounds,. FBC, U&E, LFT, CRP, amylase, bone were normal. AXR revealed gas filled small bowel loops.

Urgent abdominal CT scan confirmed dilated small bowel loops converging to the caecum suggesting intussusception as the cause of sub acute bowel obstruction. Further blood tests revealed TSH <0.02 (n 0.35–6.00), free T₄ 87.2 (n 11–26) and free T₃ 20 (n 2.6–6.2) and a diagnosis of thyrotoxicosis was made. She was started on carbimazole and propranolol via NG tube and intravenous hydrocortisone. The anaesthetic team was alerted to the risks of thyroid storm and atrial fibrillation. At emergency laparotomy the intussusception has resolved and full examination of the small and large bowel was normal. She made a good recovery and was discharged home to be followed up in the endocrine clinic. Outpatient small bowels follow through and colonoscopy was normal.

Discussion: Thyrotoxicosis, in its classical form, is easily diagnosed and treated. Many hyperthyroid patients have gastrointestinal complaints such as increased frequency of bowel movements and nausea. However, some case reports described atypical presentations with vomiting, abdominal pain or raised liver enzymes. There is also evidence of increased incidence of gastroperesis, gastritis, achlorhydria, and peptic ulcer, in hyperthyroid patients. This is the first reported case of thyrotoxicosis presenting as intussusception.

Conclusion: Abdominal symptoms can be the first and only manifestations of thyrotoxicosis; therefore we emphasize the importance of including thyroid function tests in the evaluation of patients with prolonged, unexplained gastrointestinal symptoms.